Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. E. Agency Performance Measures



The Draft White Paper notes that although some complaints analysts may specialize by line of insurance, it is beneficial for all analysts to have "a basic understanding of all lines of insurance", particularly relevant to dealing with catastrophic situations.

Consumer Satisfaction

The NAIC states that a consumer satisfaction survey is "essential to providing feedback on overall performance". It mentions alternative methods such as written surveys and self-addressed postcards, but does not offer any guidance as to a preferred method. In addition to assessing performance, the NAIC notes that consumer satisfaction surveys can be helpful in determining resource needs "by identifying how consumers learned of the availability of consumer assistance and information, the means of communication used, the reason for contact, and the consumer's age and county of residence".


The NAIC notes that states should have "quality control measures in place to monitor both the individual complaint analyst and the department performance and to ensure that complaints are being handled properly". Monitoring individual complaints analysts may include supervisory review and telephone monitoring, with factors reviewed including: the timeliness of resolution, clarity of communication, accuracy and quality of response to consumer questions, friendliness to consumers and overall consumer satisfaction.

Appendix C provides examples of supervisory review and audit forms used by Florida, Colorado and California. For example, Florida undertakes monthly audits of consumer files and annual audits of overall office policies and procedures. The Florida annual audit is quite far-reaching and includes documenting the extent of consumer outreach programs, the volume of files referred to various agencies, identifying trends, topics of concern and legislative suggestions.

Random monitoring of complaint analyst telephone calls is also suggested as a quality improvement initiative. The NAIC notes that some states may also choose to conduct "blind telephone call" investigations where staff "call the Consumer Services Section and represent themselves as consumers in order to identify areas where improvements and job training were needed".

Workload Performance Measures Including Financial Savings

The NAIC notes that currently most states monitor various performance measures such as the number of telephone calls, information requests, Internet site hits, time for resolution of complaints and the amount of money recovered. However it is supportive of benchmarking through the development of more specific outcome measures.

In terms of measuring financial savings to consumers, the NAIC recommends that states track the amount of monies recovered subsequent to the involvement of the insurance department (a differential basis), rather than simply measuring the full amount of monies recovered by the complainant.